*KNOW THE WARNING SIGNS
*In the case of multiple or severe signs, seek immediate professional help. The National Suicide Prevention Lifeline at 1-800-273-TALK (8255) provides acccess to trained telephone counselors, 24 hours a day, 7 days a week.
- Talking about suicide, death, and/or no reason to live
- Preoccupation with death and dying
- Withdrawal from friends and/or social activities
- Experience of a recent severe loss (especially a relationship) or the threat of a significant loss
- Experience or fear of a situation of humiliation or failure
- Drastic changes in behavior
- Loss of interest in hobbies, work, school, etc.
- Preparation for death by making out a will (unexpectedly) and final arrangements
- Giving away prized possessions
- Previous history of suicide attempts, as well as violence and/or hostility
- Unnecessary risks; reckless and/or impulsive behavior
- Loss of interest in personal appearance
- Increased use of alcohol and/or drugs
- General hopelessness
- Recent experience of humiliation or failure
- Unwillingness to connect with potential helpers
*Source: Tennessee Suicide Prevention Network
Editor's note: This article is the first in a three-part series about aging and suicide. It was written with the support of a journalism fellowship from the Gerontological Society of America, Journalists Network on Generations and the Silver Century Foundation.
Senior care experts know conversations around mental health, suicide and aging can be difficult, but they say that's an even bigger reason not to ignore them.
Most media and public health campaigns focus on the important issue of teen suicide, yet suicide risk factors — such as loneliness, loss of loved ones, financial strain, substance use disorders and physical decline — are much more common among seniors. As a result, Tennesseans age 65 and up are nearly three times more likely to die by suicide than those aged 10-19, according to the Tennessee Suicide Prevention Network's 2019 report, and that likelihood increases with age.
In addition to being at greater risk, older adults have unique health needs — the likelihood of two or more chronic conditions at the same time, multiple prescription drugs, physiological differences — so interventions that work for other age groups may not for older adults.
And the risk is even greater for those aging in Tennessee, where the rate of suicide in seniors is 52% above the national rate, according to the Tennessee Suicide Prevention Network.
Tyler Davis, CEO of Erlanger Behavioral Health, said many factors, including culture, contribute to Tennessee's higher rate.
"Here in this region, especially Appalachia, you've got strong values that are tied to your family loyalty, your independence, your self-reliance, modesty, pride. We don't talk about our personal problems," Davis said, adding that he believes the crisis is much worse than the data reveals because many suicides go unreported, deemed accidents or drug overdoses.
Another major issue, he said, is the national shortage of geriatricians and outpatient psychiatric providers, who become even harder to access in rural areas, especially for those with transportation and mobility challenges.
As a fellowship-trained geriatrician, Dr. Alicia Cleinman is one of the few physicians in the region who specializes in treating patients age 55 and older. She said depression and behavioral health issues are "vastly underrecognized and undertreated" in the older population, especially the World War II generation.
"Their view is they should be strong, and they shouldn't complain about things. They should just grit and bear it," Cleinman said.
Compounding the issue, normal symptoms of depression, such as sadness, fatigue and apathy, can cause "pseudo-dementia" memory loss in seniors.
"It shows different patterns on the testing," she said. "They're able to form new memories, they just can't retrieve them well."
This means seniors can be misdiagnosed as having depression when it's actually dementia that's starting to develop or vice versa.
"They are difficult sometimes to separate. It takes time and a lot of follow-up to determine whether or not treatment is improving one or the other," she said, adding patients who are diagnosed with dementia can become depressed just based on that alone.
For these reasons, Cleinman's practice at CHI Memorial's Center for Healthy Aging screens all patients for depression and employs a dedicated licensed clinical social worker, Einre Lopez, to counsel and address patients' behavioral and social needs.
"People have spent years and years coping in the same way they have done for a long time," Lopez said. "Some of them don't know why they're feeling that way or they don't know how to deal with life because they've been so independent and all the sudden that's taken away from them."
Given the barriers, both Cleinman and Davis said it's essential for providers, family members, caretakers and the community to get past the stigma and start talking.
"A lot of times, when people talk about it with me, they seem ashamed almost at first, until you tell them that it's pretty common statistically and that they're not the only one going through it," Cleinman said.
Davis said often people don't ask others if they're having thoughts of suicide for fear of introducing the idea.
"The opposite is true," he said. "If they ask the question and the person has no thoughts of self harm, then they won't think of it suddenly as an option, and the ones who are already thinking about it will now have an outlet to talk."
While untreated mental illness is one possible risk factor, experts say suicide is rarely the result of a single issue. Relationship problems, substance use, illness and stress can all increase someone's risk, and many people who die by suicide are not known to have a diagnosed mental health condition at the time of death, according to the CDC.
America's Health Rankings 2019 Senior Report paints a detailed picture of the challenges facing today's seniors.
Although people are living longer, several key areas are holding many seniors back, especially mental health, unhealthy behaviors and barriers to care.
The annual report found that excessive drinking among seniors is up 42% and the suicide rate is 16% higher than 15 years ago, with large disparities across gender in measures of mental health.
While females are more likely to report mental distress and be diagnosed with depression, male seniors are six times more likely to die by suicide.
The Southeast's higher rates of obesity and diabetes can compound the issue, since comorbidities, or the existence of two or more chronic conditions at the same time, and decreased mobility may create a snowball effect. It also means that conversations about mental health take a backseat, as time spent at the doctor is often spent on physical ailments.
Davis said patients and providers need to shift to more preventative screening for mental health issues similar to the way they screen for diabetes or heart disease.
"You don't wait until your teeth are rotting and falling out before you go to the dentist. Why is your mental health different?" Davis said.
And most importantly, Lopez said, watch for changes in behavior and don't hesitate to ask the older adults in your life questions about how they're feeling.
"I think that's the biggest thing," she said. "Some of them say, well, nobody asked provide them an opportunity to speak, work from there and just give them some hope that we care."
Contact Elizabeth Fite at firstname.lastname@example.org or 423-757-6673.